Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670093 (X3) Date Survey Completed 04/16/2019
Name of Provider or Supplier Aspire Hospital Street Address, City, State 2006 South Loop 336 West, Suite 500, Conroe, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0438 FORM AND RETENTION OF RECORDS
CFR(s): 482.24(b)

The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.


This STANDARD is not met as evidenced by:
Based on record review and interview: A. The facility failed to ensure that the seclusion/restraint documentation on 5 of 5 patients (patient #1, #2, #15, #16, and patient #17) was properly filed and retained in the patient's chart. B. The facility failed to ensure that changes to the medical record were documented according to their policy in 1 of 1 patient records (patient #15). Findings: A. Records properly filed. Record review of policy, "Restraint and Seclusion" reviewed/revised December 31, 2018, showed that restraint and seclusion is to be documented in the "patient's medical record." Record review of the seclusion/restraint packet for patients #1, #2, #15, #16, and #17 showed: "Original copy stays on chart." In an interview with Staff A, Quality Director, on 04/11/19 at 11:00 AM, he stated that the documentation of a patient's restraint or seclusion is not kept in the patient's chart; they are kept in his office in a file. B. Changes to the medical record. Record review of policy, "Progress Record Documentation" reviewed/revised December 31, 2018, showed: " ... The documentation is to be ... accurate ... 8.0 The medical record is a legal document: thus, it includes facts ... 15.0 If there is a need to do a 'late entry' ... Put current date, time ... Label entry as 'late entry' ... Specify for what date/time it is a late entry ... Document and sign name." In an interview with Staff A, Director of Quality, on 04/16/2019 at 11:00 AM, he stated he could provide five of the latest seclusion/restraint packets. [Staff A provided the seclusion/restraint packets for five patients, one of them was for Patient #15.] Record review on 04/16/2019 at 12:00 PM of the seclusion/restraint packet for Patient #15, dated 03/06/2019 at 5:17 PM showed: Part III - RN or MD Face-to-Face Evaluation; Performance Improvement: Special Treatment Procedure; and Special Treatment Procedure Flowsheet were all blank. Record review of the seclusion/restraint packet for Patient #15, dated 03/06/2019 at 5:17 PM that was faxed to the surveyors on 04/26/2019 showed changes made to the original seclusion/restraint packet. These changes included: 1. Part III - RN or MD Face-to-Face Evaluation: "Alert. Responsive to questions. Refused vital signs. Unable to conduct physical assessment, appears in no harm, verbalizes no harm. Patient currently out of seclusion/restraint (circle which) at this time." It was signed by Staff G and dated 03/06/2019 at 1800. 2. Performance Improvement: Special Treatment Procedure: Date: 3/6/19. RN notified 1740. Face to face within 1hour time: 1800. Name of staff solely monitoring patient's stability during physical hold: Staff K. 3. Special Treatment Procedure Flowsheet: The following items were circled: Behavior: Yelling, Hitting, Cursing. Interventions: Physical restraint, explained criteria for released [sic], Physical assessment, Seclusion;/Restraint Discontinued. Response: Talking with staff. In a telephone interview with Staff C on 4/26/19 at 8:40 AM, she was asked to compare the original seclusion/restraint packet for Patient #15 with the faxed over copy. She stated the faxed copy was different from the original copy obtained during the survey. She stated she was unsure who had added documentation to Part III - RN or MD Face-to-Face Evaluation, Performance Improvement: Special Treatment Procedure, and Special Treatment Procedure Flowsheet. As she reviewed the discrepancies, she stated, "It concerns me very much," adding the changes should have been documented as a "late entry." In a telephone interview with Staff A, Director of Quality, and Staff G, former DON on 4/26/19 at 11:30 AM, they were asked about the discrepancies with the two restraint and seclusion packets for Patient #15. Staff A stated that adding omitted information to medical records was standard practice when closing out the medical records. During the same telephone interview, Staff G stated that he was the person who altered Patient #15's seclusion/restraint packed on 04/25/2019, adding that he back-dated his entry to 03/06/2019 at 1800 and did not designate it as a "late entry." He also stated he was the nurse who performed the Face-To-Face evaluation. He concluded by saying that he should have written "Late entry" on the form, as well as timed and dated it, and that it was "a mistake on my part."